Background: Airway foreign bodies present as emergencies, are not uncommon in developing countries like Nigeria, and can occur in all age groups. They present great difficulties for both parents and medical practitioners in general and the otorhinolaryngologist in particular. Tracheobronchial foreign bodies may endanger the life of the patient depending on the type, size, and location of the foreign body in the airway tract. We aim to look at the management of tracheobronchial foreign bodies and present a maiden article on the management of tracheobronchial foreign bodies in our center. Patients and Methods: This was a retrospective review of all patients seen at the Emergency Unit and Consultant Clinics of the National Ear Care Centre, Kaduna, Nigeria, with diagnosis of foreign bodies in the airway (the tracheobronchial area). Medical records of patients seen between January 1, 2012, and December 31, 2016, were reviewed. Data generated from the case files were analyzed descriptively. Results: Thirty-four patients presented with foreign bodies in the airway. This comprises 25 males and 9 females in a ratio of 2.8:1. Age at presentation ranged between 11 months and 27 years; the mean age was 7.02 ± 5.46 years. The predominant age group affected was 0–9 years. Twelve patients had a preliminary tracheostomy before endoscopic removal of the foreign body. Twenty-seven patients had rigid bronchoscopy and foreign body removal while 3 patients had flexible bronchoscopy, 1 patient had direct laryngoscopy, and 3 patients had tracheoscopy and foreign body removal. Majority of the foreign bodies were plastic in origin. Conclusion: Airway foreign bodies are acute emergencies, especially in pediatric age groups, and the best modality of treatment is endoscopic removal under general anesthesia.

Airway foreign bodies present as emergencies, are not uncommon in developing countries like Nigeria, and can occur in all age groups.[1] They present great difficulties for both parents and medical practitioners in general and the otorhinolaryngologist in particular. Tracheobronchial foreign bodies may endanger the life of the patient depending on the type, size, and location of the foreign body in the airway tract.[2]

Patients usually present with cough, stridor, and occasionally with difficult breathing depending on the size of the foreign body and site of foreign body impaction. The most common site for bronchial foreign bodies impaction is the right main bronchus; this has to do with the orientation of the right bronchus being shorter, wider, and more vertical.[2],[3],[4]

Attempt at removal by an untrained staff is associated with severe complications.[5] Methods employed in the retrieval of tracheobronchial foreign bodies include the use of rigid bronchoscope, flexible bronchoscope, or in some cases via an external thoracotomy approach.[6],[7] Due to the ability of the rigid bronchoscope to maintain ventilation of the patient during the procedure, most surgeons prefer rigid bronchoscopy to flexible bronchoscopy for retrieval of tracheobronchial foreign bodies.[3] Bronchoscopy can be employed as either a diagnostic or a therapeutic tool depending on the nature of aspirated foreign body.[8] Complications may arise from either the presence of foreign body in the tracheobronchial tree or the method (s) adopted for its removal.[9],[10]

We aim to look at the management of tracheobronchial foreign bodies and present a maiden article on the management of tracheobronchial foreign bodies in our center.

Patients and Methods

This was a retrospective review of all patients seen at the Emergency Unit and Consultant Clinics of the National Ear Care Centre, Kaduna, Nigeria, with diagnosis of foreign bodies in the airway (the tracheobronchial area). Ethical approval was obtained from the health research ethics committee of the study center. Medical records of patients with tracheobronchial foreign bodies seen between January 1, 2012, and December 31, 2016, were reviewed.

All patients with complete records based on the study design were included in the study. Patients seen during the period under review with incomplete records in their case files were excluded from the study.

Data generated from the case files included biodata (age and gender), clinical history (history of foreign body aspiration/inhalation, duration before presenting to the hospital, cough, difficulty with breathing, intervention offered at home before presenting, and associated stridor), examination findings (respiratory rate, chest examination findings, and cardiovascular status), plain radiography of the soft tissue neck and chest, intervention (procedure adopted for removal of the foreign body, duration of the procedure), nature of the foreign body, complications arising from removal, outcome (discharge, referred, or died) were analyzed descriptively with Statistical Product and Service Solutions (SPSS), Chicago, Illinois, USA, Inc., version 20. Relationships between discrete variables were analyzed with Pearson's correlation and level of significance was set at P< 0.05.

Limitations

These limitations encountered while undertaking the study include:

Incompleteness of clinical records in some patient's case notes hence excluded from the study

No documentation of actual challenges faced during the operative procedures that took longer time.

Results

Thirty-four patients presented with foreign bodies in the airway during the period under review. This comprises 25 males and 9 females with a m:f ratio of 2.8:1. Age at presentation ranged between 11 months and 27 years; the mean age was 7.02 ± 5.46 years. The predominant age group affected was 0–9 years. Majority of the foreign bodies were plastic in origin [Table 1].

There was no significant statistical relationship between gender of the patients and the days spent on hospital admission (P = 0.467, R = 0.129).

All the patients (34, 100%) presented with a history of foreign body aspiration, 31 (91.2%) of the reviewed patients presented with difficulty with breathing. Thirty-one (91.2%) of the patients presented with cough while only 7 (20.6%) were febrile at presentation. Twenty-five (73.5%) of the patients were in respiratory distress, of which 21 (84%) were stridulous. Three (8.8%) patients were mildly dehydrated while only 1 (2.9%) of the patients was cyanosed. Other examination findings include fever in 7 (20.6%) patients at presentation. The duration of symptoms before presenting to the health facility is shown in [Table 2].

Relationship between duration of symptoms and outcome (discharged, referred, or died) was not found to be statistically significant but has a weak positive correlation (P = 0.369, R = 0.159).

X-rays of the chest revealed pneumonic changes in 6 (17.6%), air entrapment in 23 (67.65%), and metallic density in 3 (8.82%) of the patients while X-rays of the soft tissue of the neck anteroposterior and lateral views showed the presence of foreign body in 2 (5.9%) of the patients evaluated.

Twelve (35.3%) of the patients had an emergency airway management in the form of an emergency tracheostomy on account of an imminent upper airway obstruction before the definitive procedure was carried out. Twenty-seven (79.4%) patients had rigid bronchoscopy and foreignbody removal. All the definitive procedures for removing the foreign bodies were done under general anesthesia. The procedures adopted for foreign body removal is shown in [Table 3].

The procedure performed took 20 min minimally; the mean duration was 60 ± 36.45 min while the maximum duration was 2 h. Direct Laryngoscopy and foreign body removal took 20 min while rigid bronchoscopy and removal of a foreign body in the left segmental bronchus took 2 h. Patients who had direct laryngoscopy and foreign body removal without a preliminary tracheostomy stayed in the hospital for 24 h, while patients who had flexible bronchoscopy and foreign body removal following unsuccessful attempts with a rigid bronchoscope and had a preliminary tracheostomy were admitted for 19 days. Relationship between duration of procedure and days spent in hospital admission was found to be statistically significant with a moderately strong positive correlation (P = 0.00, R = 0.62), while duration of procedure performed and outcome was not found to be statistically significant but had a weak positive correlation. Preliminary tracheostomy and length of hospital stay were found to have significant statistical relationship but with moderately weak negative correlation (P = 0.003, R = −0.492).

Varied configurations and nature of foreign bodies were retrieved during the procedures and the nature of the foreign bodies retrieved is shown in [Table 4].

Twenty (58.82%) of the retrieved foreign bodies were in the right main bronchus while 7 (20.59%) were found lodged in the left main bronchus. In the same vein, a foreign body was found in the subglottis and was removed via direct laryngoscopy. Three (8.82%) foreign bodies were found in the trachea while 3 (8.82%) were found in the right lobar bronchi necessitating the use of flexible fiberoptic endoscopes for their removal.

Complication rate of 17.60% was documented from both the foreign body impaction and the procedure adopted for their retrieval. Details of the documented complications are shown in [Table 5].

Complications were found to have a statistically significant relationship with the type of foreign body retrieved, with a moderately strong positive correlation (P = 0.017, R = 0.524). Both the duration of symptoms and the definitive procedure performed were found not to have a significant statistical relationship with complications (P = 0.991, R = 0.230). Airway management in terms of preliminary tracheostomy was also not statistically significant but has a moderately strong positive correlation with complications developed by the patients.

The mean hospital stay was 5 ± 4.19 days, minimum was 1 day and maximum was 19 days. The distribution of duration of hospital stay is presented in [Table 6].

Tracheobronchial foreign bodies usually present as emergencies with varied degree of severity. Children are usually affected, especially while playing with the objects. Parents are usually not at the scene of the event, so most often history of foreign body aspiration is unlikely to be obtained from the parents. From this study, 26 (76.5%) of the cases of tracheobronchial foreign bodies were seen in those patients <9 years of age. This finding agrees with an earlier study conducted in the center [2] where aerodigestive foreign bodies were mostly seen in this age group. Alabi et al.[11] also reported similar pattern in North Central Nigeria where 84.9% of the patients in their series were between 2 and 4 years of age. Onotai and Ibekwe [12] also have similar finding in their work. Victor [6] documented similar findings whereby 86% of the patients were <12 years of age. Gender wise, males were found to be more affected consisting of 73.5% of the patients.

The mean age of our patients at presentation was 7.02 ± 5.46 years, minimum age being 11 months while the maximum age of the patients was 27 years. Victor [6] in Ibadan Southwestern Nigeria found out the minimum age of the patients to be 7 months, which was much younger compared to what we found in this study. Fidkowski et al.[13] in a review of 12,979 cases of tracheobronchial foreign bodies with special emphasis on the anesthetic considerations found out that most of the patients who aspirated foreign bodies were younger than 3 years of age. Christina's finding might not be unconnected to the fact that the reviewed patients in their series were only children.

Eleven (32.4%) of our patients presented within the first 5 h of foreign body aspiration; however, there was no significant statistical correlation between the time of presentation and ultimate outcome of the management modality employed. In an earlier study conducted at the study center,[2] majority of the patients (63.83%) with upper aerodigestive foreign bodies presented to the facility within the first 24 h of foreign body ingestion/aspiration. Consequent upon the study, it was found out that patients with airway foreign bodies tend to present much earlier due to symptoms such as stridor and difficulty with breathing. Our finding in this study also agrees with the work of Majori et al.[10] where approximately 50%–75% of cases of foreign body aspiration in children present within 24 h of aspiration. This might not be unconnected with the inconveniences of difficulty with breathing.

In this study, 31 (91.2%) of patients with tracheobronchial foreign bodies presented with difficulty with breathing and similar proportion presented with cough; our findings contrast with those of Alabi et al.[11] where approximately 33% of the patients in their series presented with either difficulty with breathing or stridor. This might be explained by the fact that in their series, both airway and digestive tract foreign bodies were reviewed.

Fifty percent of our patients were acutely ill looking at presentation, characterized by either painful or respiratory distress. However, only 3 (8.8%) patients were mildly dehydrated, which could be due to respiratory distress and fever among those patients who presented after the first 24 h.

X-rays of the soft tissue neck anteroposterior and lateral views as well as that of the chest are believed to be essential in the overall assessment and management of the patients. In this study, 32 (94.1%) of the patients had abnormal chest X-rays that are suggestive of foreign body lodgment in the tracheobronchial tree. In Turkey, Bayram et al.[14] found radiopaque image of the foreign body in 88.4% of the patients they reviewed. Other findings in their series were hyperinflation and bronchiectatic changes, but were not significant. In the same vein, Hamid et al.[15] in Iran, Nisar et al.,[16] and Narasimhan et al.[17] in India as well as Kunjan [18] in Nepal demonstrated obstructive emphysema in about 50% of their patients.

In instances where doubts exist during radiologic evaluation with plain radiographs, lateral decubitus chest radiographs should be done in children, while in adults, additional views should be done in the expiratory phase. The most common limitation of such, especially in children, is cooperation of the child. Tseng et al.[19] and Pugmire et al.[20] in the US opine that in difficult cases, fluoroscopic dynamic evaluation of the diaphragm is effective in detecting unilateral bronchial foreign bodies, being able to detect reduced diaphragmatic excursion on the affected side. When plain radiographs fail to detect tracheobronchial foreign bodies despite high index of suspicion, Ehab et al.[21] and Lalendra [22] suggested the use of multidetector computed tomography combined with virtual bronchoscopy as an effective way to increase the yield.

Our findings contrast Majori et al.[10] where about two-third of the patients in their series had normal plain radiographs. It is pertinent to note that negativity of a plain radiograph does not necessarily exclude the presence of a tracheobronchial foreign body, especially in patients who presented with a history of foreign body aspiration. Blanco Ramos et al.[23] in Spain recommended that normality of a chest radiograph should not obviate bronchoscopy.

All the patients had endoscopic removal of foreign body in their tracheobronchial area under general anesthesia depending on the site of impaction. Fidkowski et al.[13] recommended general anesthesia for bronchoscopy and removal of foreign bodies lodged in the tracheobronchial area. Preliminary tracheostomy was performed in 12 (35.3%) of the patients, mainly due to an impending upper airway obstruction and also consequent upon the result of the soft tissue neck X-ray. Intraoperatively, some of the foreign bodies were noted to have migrated from the subglottis into the trachea and the bronchi. In a previous study at the study center,[2] it was documented that 18% of the patients with aerodigestive foreign bodies had preliminary tracheostomy before the definitive procedure was carried out to remove the foreign bodies. In the previous study, both digestive and airway tracts foreign bodies were analyzed; this might be responsible for the small proportion of tracheostomized patients before foreign body removal.

Rigid bronchoscopy in foreign body removal was the most frequent procedure performed in almost 80% of the patients. Majori et al.[10] and other studies [1],[2],[11],[13] have found out that rigid bronchoscopy is a safe procedure in removal of tracheobronchial foreign bodies in both adults and pediatric age groups. During the procedures, majority of the retrieved foreign bodies were of plastic origin, ranging from toys, whistles to shirt buttons; few were of vegetative origin and coincidentally 50% of the patients with vegetative foreign bodies presented with fever and cough, likely to be from continuous irritation of the airway by the vegetative matter. Our findings agreed with the findings of Falase et al.[4] where majority of the foreign bodies in their series were of inorganic origin.

Complication rate of 17.6% was recorded from either the foreign body impaction or the procedure adopted for removal of the foreign body. This is higher than the previously documented value of 6.38%.[2] This can be explained by late presentation to the facility as some of the patients presented with complications attributable to the presence of foreign body in the airway.

In this study, there was a significant statistical relationship between duration of the procedure performed and the length of hospital stay.

Conclusion

Airway foreign bodies are emergencies and should be managed as such. Outcome depends on the duration of symptoms before presentation, area of lodgment of the foreign body, and type of foreign body. Bronchoscopy using rigid and flexible bronchoscopes is a safe procedure for extraction.